Preemptive Ivus And Fusion-guided Electrocautery-assisted Aortic Septotomy For Endovascular Repair Of Chronic Aortoiliac Dissecting Aneurysms
Kyongjune B. Lee, MD, Pavarino L. Felipe, MD, Jesus Porras Colon, MD, Mirza S. Baig, MD, Melissa L. Kirkwood, MD, Marilisa Soto-Gonzalez, MD, Andres V. Figueroa, MD, Timaran H. Carlos, MD.
UT Southwestern Medical Center, Dallas, TX, USA.
OBJECTIVE: Endovascular repair of chronic dissecting aortoiliac aneurysms is challenging given the rigid septum, compressed true lumen, and target vessels in the false lumen. We have used electrocautery-activated guidewire septotomy prior to stent-graft implantation under intravascular ultrasound (IVUS) and fusion guidance.METHODS:During a 12-month period, seven patients underwent electrocautery-assisted septotomy. The aortic septum is crossed through a pre-existing entry or via electrocautery-activated .018-in Astato XS20 wire under IVUS and fusion guidance. The penetrated wire is snared and pulled through the ipsilateral femoral access. A 1-cm length of the middle of the Astato wire coating is kinked in a three-sided polygonal configuration, denuded using a #15 blade, and positioned at the apex of the septum. Both ends of the Astato wire are insulated with .018-in microcatheters, while the back end of the wire is denuded and connected to cautery. Gentle traction is applied to the wire, and short bursts of electrocautery cutting are applied at 60W.RESULTS: The technical success of the septotomy was 100%. No incidences of visceral or lower extremity malperfusion or vascular injury occurred. Two patients underwent concomitant thoracic endovascular aneurysm repair, and five underwent fenestrated/branched endovascular aneurysm repair after septotomy. All target vessels were successfully stented. A distal landing zone seal with the exclusion of false lumen was achieved in 6 out of 7 patients (86%). One patient required embolization of the false lumen of the celiac artery following septotomy. The true lumen mean diameter and cross-sectional area of the descending thoracic aorta after septotomy was expanded by 10.8 ± 8.5mm (relative mean diameter expansion 71%) and 3.24 ± 1.78cm2 (relative mean cross-sectional area expansion 136%). For patients who required septotomy through the common iliac arteries, the mean true lumen was expanded by 8.8 ± 3.7mm (relative mean diameter expansion 125%) and 2.37 ± 0.92cm2 (relative mean cross-sectional area expansion 259%).CONCLUSION:IVUS and fusion-guided electrocautery-assisted aortic septotomy is safe and facilitates true lumen expansion with seal and false lumen exclusion. The durability and long-term outcomes of this aortic septotomy technique used for endovascular repair of chronic dissecting aneurysms remain to be elucidated. 
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